Also known as “all the things no one told me about becoming a flight nurse and I was too afraid to ask.”

If you spend enough time around flight medicine, you’ll notice something interesting: we spend a tremendous amount of time preparing people for the clinical side of the job. We teach ventilators. We teach hemodynamics. We teach advanced airway management, critical care pharmacology, blood administration, flight physiology, and the thousand other things required to keep very sick people alive in very inconvenient places. You know… important life saving stuff.

What we don’t teach is how to actually live this job. When I became a new flight nurse nobody sat me down during orientation and explains what happens when you’re eight hours into a humid summer shift, your flight suit has become a personal bog, you’ve consumed enough caffeine to qualify as a controlled substance (basically when you start to hear colors), and dispatch sends you to a hospital two hours from anywhere that resembles civilization before you had a chance to pee. I had to learn all of it through trial and error essentially.

Nobody teaches the proper technique for surviving a gross ER patient bathroom in a nomex onesie with someone’s unlabeled urine specimen looking at you sideways from the sink. Nobody discusses the emotional significance of finding the crew-room shower full of Tribbles (your crew mates’ hair) in the drain after a 20-hour day and something crusty/unidentifiable is chilling on your forearm.

Nobody explains why every experienced flight clinician owns an oddly specific collection of chapstick, anti-chafing or -stank ass products, backup socks and under roos (most likely unmatching, potentialy with holes), emergency snacks, phone chargers, more pain-relievers than Walgreens, and enough caffeine to knock you both into and subsequently out of V-tach.

Most flight crews eventually learn these lessons the same way they learn everything else in medicine: through a combination of observation, suffering, and poor decisions. The reality is that flight medicine as whole isn’t just a job but rather a lifestyle. For some of you that life is 12-hour shift where you go home afterward, sleep in your own bed, and maintain a reasonably healthy connection to society. For others (like moi)….it’s a 24- or 48-hour assignment where you essentially move into a base with a group of coworkers who slowly transition from colleagues to roommates, family members, and occasionally hostage negotiators at 3am.

Either way, there are survival skills nobody teaches: the practical stuff, the weird stuff, or the “I wish someone had told me this three years ago” stuff. NEVER FEAR! I got you! Consider this your Unofficial Guide to the Activities of Daily Living in Flight Medicine*!

*A field manual for moisture management, sleep preservation, strategic snacking, flight-suit bathroom logistics, communal living, and maintaining a small shred of dignity while spending your high-speed career in a helicopter.

Part 1 of this series will include dressing for the weather, hydration and cooling solutions, and navigating the bathroom situation.

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Dressing for Success (and Mitigating Inevitable Swamp Ass)

Flight medicine exposes you to a truly impressive variety of climates, often within the same shift depending on where you work. You may start your morning standing on a frozen highway shoulder in March, spend the afternoon in a hospital that appears to refrigerate its patients as if theyre preparing them to go to the morgue, and end the day baking in a different hospital that is hot enough to punish Satan for his transgressions. Through all of it, you’ll be wrapped in a flight suit that somehow manages to be simultaneously too hot, too cold, and slightly uncomfortable at all times because the crotch wants to greet your internal organs.

One of the biggest surprises for new flight clinicians is how much energy gets devoted to managing the environment inside the flight suit itself. We spend years learning how to manage ventilators, but almost no time discussing how to manage the small ecosystem developing between our skin and our onesie. Skin flora really do love a moist girlie.

Most programs require cotton base layers, which is great for fire safety and considerably less great for comfort. Cotton absorbs sweat like it’s trying to set a world record and once it’s wet, it remains wet. Eventually it begins clinging to your body with the determination of an emotionally needy ex— at least I assume thats the analogy because my ex’s stay away with good reason. Since most of us don’t get much say in the matter the goal then becomes learning how to strategically manage the suck.

For me, that starts with keeping everything as lightweight as possible. Compression shorts are one of the greatest contributions modern science has made to flight medicine. Good socks are worth spending money on, even if it feels ridiculous to hand over twenty dollars for something that lives inside your boots. Backup underwear should be considered mandatory equipment. And ladies, this is wear you sacrifice sexy for comfy and embrace the cotton granny life (“one of us, one of us”). No seriously, there are few morale boosters more powerful than changing into a fresh pair halfway through a shift that has gone sideways. It’s amazing how quickly your outlook on life improves when you’re no longer marinating in your own poor decisions. Also for my bra-wearing cohorts say it with me, “sports bra, burn underwire.”

The opposite problem occurs in cold weather. New flight clinicians often assume they need the thickest layers possible only to discover that flight medicine consists of repeatedly transitioning between freezing and sweating every thirty minutes. My least favorite thing in winter was having my layers to survive the single digit outside and then having to spend hours packaging in the Tropics of NICU. Thin layers work better than bulky ones especially ones you can shed. Hand warmers stuffed into random pockets are worth their weight in gold and seriously don’t sleep on footwarmers. Finally…wool socks,which continue to prove that sheep solved a problem we never quite figured out ourselves because being cold is baaaaad. I’ll see myself out.

Now… if you like to live dangerously… all natural fibers are the safest things to wear in flight. However, I’m going to be very blunt and candid on this next part. I have always worried more about hypo/hyperthermia in our work environments moreso than getting burnt and seran-wrapped by synthetic fibers. I personally do wear synthetic clothing designed for hot or cold environments because the likelihood of me getting injured from those things is higher than the fire in the cockpit. Please use your best judgement on this and lean into your programs for guidance. I’m not going to be the one to tell you to break the rules.

THAT ALL BEING SAID: Eventually, all roads lead to moisture management. (I said moist and I’m not apologizing for it)

Now we’re discussing the kind of operational knowledge that only comes from experience. The combination of heat, stress, vinyl seats, whatever legal stimulants you consume, and long shifts creates conditions capable of generating their own biome inside your Gibson Barnes. Anti-chafing products, baby wipes, powder, fresh socks, dry shampoo, and backup underwear become less of a luxury and more of a survival strategy. Experienced flight clinicians don’t pack these items because they’re high maintenance rather they carry them because they’ve suffered enough to know better and all the partners rejoiced for their destankifaction efforts.

There is also a time-honored tradition among flight crews of stepping outside the aircraft and pretending to be deeply invested in weather conditions when in reality they’re simply trying to create enough airflow to cool down portions of their anatomy that haven’t seen fresh air in twelve hours. Desert crews understand this instinctively. If you see someone Captain Morgan’ing on a skid when the wind blows… mind your business. Summer flight medicine in Arizona often feels like existing one degree below spontaneous human combustion. You do what you can to air out and cool down. Cold-weather crews like to think they’re immune until they walk into a heated hospital wearing thermal layers and immediately transform into juicy rotisserie chickens in a Costco wrapper.

The lesson here is simple. Take care of yourself before discomfort becomes a problem. Change your socks. Bring the backup underwear. Protect your skin. Nobody has ever received an award for being the most miserable person at the base, and despite what flight medicine culture occasionally suggests: suffering is not a competitive sport.

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How Not to Become a Dried-Out Sea Monkey (Beyond “Just Drink Water”)

One of the most annoying pieces of advice in flight medicine is also one of the most common: “stay hydrated.” Gee…Thanks. I’ll be sure to get right on that as I pop open my second Sadness Soda ™ of the day (credit to my partner Aaron for that name).

The people giving this advice are never wrong….exactly. They’re just dramatically underselling the challenge. Staying hydrated in flight medicine isn’t the same thing as remembering to carry a water bottle around on a trip to Target. It requires actual planning because the job seems specifically designed to interfere with every normal human activity and that includes drinking water.

Somewhere along the way many of us develop a toxic enough relationship with caffeine that would concern a cardiologist and probably qualify us for a short stint in rehab. Entire flight programs appear to function on a delicate ecosystem of energy drinks, coffee, and mutual irritation. We drink caffeine because we’re tired but we’re tired because we work weird schedules but we work weird schedules because somebody thought it would be a good idea to combine critical care medicine with aviation…and we have to fund our extravagant lifestyles.

However the problem is that after your second coffee and first energy drink of the day, your brain starts counting those fluids as hydration but they are not hydrating. They’re just beverages wearing hydration’s skin.

I’m going to hold your hand while I say this, ok? At some point… actual water has to enter your body.

This becomes especially obvious when you work in places like where I work in Arizona where summer feels less like a season and more like a personal attack. Summer flight medicine in Arizona often feels like the devil opened the oven door to check on his cookies and accidentally created an entire state. Literally everything in Arizona wants to kill you and the heat is at the top of the list. Arizona is a state that the sun gives its middle finger to for 3/4’s of the year. The heat doesn’t care how experienced you are. It doesn’t care how smart you are. It doesn’t care that you were “only outside for a minute.” It just sits there waiting for you to make a mistake. It reminds me of a creepy voyeur watching you make poor life choices.

One of the best tricks I ever learned was the partially frozen Camel Back hack. Not fully frozen. That’s rookie behavior. A completely frozen Camel Back is just an oddly shaped brick that just feels weird but if you fill it halfway and lay it flat to freeze it becomes something magical. Then take that and slip it down the back of your flight suit. You get cold water for hours to daintily sip on and for a brief period of time it feels like someone installed air conditioning directly against your spine (heavy on the “brief”). During an Arizona summer that qualifies as a religious experience.

The other lesson I learned the hard way is that just water isn’t always enough. When you’re sweating through a flight suit, hauling equipment through the major tertiary hospitals, and spending hours in triple-digit temperatures, you’re losing more than fluid. Eventually you reach a point where you can drink water all day and still feel vaguely terrible (more than usual if youre over 30) and that’s usually your body reminding you that electrolytes exist and perhaps you should stop treating them like a suggestion.

The truly dangerous thing about dehydration is that it rarely announces itself in a dramatic fashion. Most people expect heat illness to look like collapsing on a helipad when in reality, it usually starts with becoming progressively dumber. You get a headache. Then you become irritable. You can’t seem to focus and simple tasks require an unreasonable amount of concentration. You find yourself staring at equipment you’ve used a thousand times while your brain makes the AOL dial-up noise. AND because we’re healthcare professionals our response to these warning signs is usually to ignore them because we’d know if we were dehydrated…right?

Flight clinicians are exceptionally good at recognizing dehydration in patients although we are considerably less talented at recognizing it in ourselves. We will spend an entire shift teaching about heat exhuastion while surviving on half a bottle of water and three energy drinks.

Eventually you reach what I like to call the Desert Lizard Phase (noun): This is the point where your lips are dry, your urine resembles sweet tea, and you’ve developed an emotional attachment to the nearest air conditioner. Every inconvenience feels personal. Every task feels harder than it should. You’re technically functioning but only in the same way a phone functions when it’s at 2% battery. The frustrating part is that all of this is preventable. Is it glamorous, exciting, worthy of a conference lecture…no, no, and also no. Its simple and just plain preventable.

So here is how you do it: It drinks the water (stop pretending your energy drinks count as hydration) and it uses the electrolytes or it gets the hose, again… and by hose I mean probably a bag of saline in the back of your least favorite ground crew’s vanbulance.

Hydration is one of those things we all know is important and yet we routinely ignore until we start wondering why we’re getting headaches, snapping at our partners, and making questionable life choices. This becomes especially true when you are now working in a flight suit that doesn’t breathe, out in the elements, and slowly getting dehydrated at altitude. Unlike me, heat exhaustion doesn’t announce itself with dramatic fanfare. It sneaks up on you while you’re standing on asphalt in the sun, carrying equipment, wearing layers of protective clothing, and surviving primarily on coffee, beef jerky, and hostility. By the time you recognize it, you’re already behind.

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The Bathroom Olympics

There are many things people imagine when they picture a flight clinician: helicopters, high speed critical care badassery, cool flight suits and maybe a slow-motion walk across a helipad while Hans Zimmer music plays in the background. What they do not imagine is a grown adult trying to hoover over the toilet in a small municipal airport bathroom while desperately trying to keep a flight suit from touching a floor that appears to have escaped several public health investigations. And yet…somehow, that is a much more accurate representation of the job some days.

One of the strangest parts of flight medicine is how quickly you learn that basic human needs become logistical challenges. Eating becomes a challenge. Sleeping becomes a challenge. Going to the bathroom becomes a challenge. Things that most people accomplish without a second thought suddenly require planning, timing, strategy, and occasionally a small amount of luck. And before I jump into that, I’d like to say this is mostly aimed at women but this goes for the men too.

When I first started flying, I operated under the same assumption most new flight clinicians do, “I’ll just go before we leave on a call.” I mean that sounds reasonable until you actually start doing the job. Now the tones drop, your agency expects dispatch to launch in seven minutes, you need to collect your blood out the fridge, push the aircraft out of the hangar or secure the air-conditioning unit, you still need to walk-around, and, and, and… then you’re trying to power-pee while hugging the sleeves of your flight suit for dear life.

“I’ll go when I need to.” The phrase assumes you’ll have time when the dispatch comes. You don’t always. You might be launching in that seven minutes. You might be launching after 30 minutes of standby. Flight medicine exists in a constant state of “it depends.” The quick transfer becomes a trainwreck stabilization case. The local flight becomes a cross-state adventure. The patient who was “ready to go” somehow isn’t or doesn’t have a receiving bed assignment. And your bladder, unfortunately, refuses to exercise flexibility. Lesson: go when you first notice you have to and have the time… don’t wait until its urgent.

Over the years…I’ve become convinced that the human bladder is one of the most selfish organs in the body. It doesn’t care about scene times, flight times, launch requests, or weather delays. It doesn’t care that you’re twenty minutes from the nearest bathroom or that you’ve just strapped a critically ill patient into the aircraft. It wants what it wants. Immediately. The bladder is the honey badger of the body: it does not give a single f!ck. And don’t get me started on the poo-panic you get when you’re still 40 minutes out from the receiving.

Women eventually discover that peeing in a flight suit is less of a bodily function and more of an acquired skill. Nobody teaches it during orientation. There isn’t a competency checklist. There should be. At some point you learn how much of the flight suit needs to be unzipped, where to place your sleeves, and how to accomplish all of this without allowing any portion of the suit to touch the floor or toilet bowl. This becomes increasingly difficult the smaller the bathroom gets and the more horrifying the bathroom becomes. It’s a process that requires balance, coordination, and occasionally the flexibility of a circus performer.

So, for the women new to flight… let me help you out. Stay away from the toilet when you unzip, fold your sleeves into the crotch of your flight suit, and tuck them into each leg to secure them. Use one hand to hold it away from the bowl. Voila. Seems simple but several people I’ve spoken to literally took a few shifts to figure it out and the panic I felt when a sleeve touched my all-male base’s bathroom floor cannot be fully expressed in writing.

The men reading this are probably wondering why any of this is complicated. Respectfully, I do not wish to hear from you at this time. Your flight suits zip up from the bottom. Stand closer to the damn toilets, its not as long as you think and your stream isn’t that powerful. I say that with immense love but blunt honesty. If you don’t believe me, take a UV light and look at the front of the toilet and floor. Yeah. Enough said.

ER and muncipal airport bathrooms deserve their own discussion entirely. Like our patients (and most of our colleagues), they exist on a spectrum. Sometimes you walk into a restroom clean, stocked with quality two-ply, and so well-maintained that you briefly consider writing a positive Google review. Other times you open the door and immediately begin reevaluating every decision that brought you to that exact moment and internally ask if you’re up to date on your shots.

The challenge is that you never know which version you’re getting and by the time you’ve gathered enough information to make an informed decision, you’re already committed. It leaves you feeling ick. Cue small individual wipes. I firmly believe wipes should be considered medical equipment. Not convenience items. Not optional supplies. Medical. Equipment. Period.

Throughout my career, wipes have solved an astonishing number of problems. They’ve cleaned hands, faces, equipment, boots, flight suits, coffee spills (as seen on my Instagram reels), and whatever else mess I find. After enough years in flight medicine, you stop viewing wipes as a hygiene product and start viewing them as a universal problem-solving tool.

The longer you do this job, the more you appreciate small comforts. A clean bathroom with actual two-ply toilet paper starts to feel like a luxury resort. A sink with soap feels oddly exciting. The chance to rinse your face, change your socks, or spend thirty uninterrupted seconds not solving somebody else’s problem becomes disproportionately rewarding.

These things sound insignificant until you’ve spent ten hours moving between hospitals, helipads, ambulances, and aircraft. Nobody talks about these things because they aren’t sexy. They don’t make for compelling reels. Nobody posts motivational social media content about successfully peeing without contaminating your flight suit. Trust me on this.

When I first started flying, I thought becoming a good flight clinician meant mastering the medicine and aviation. Years later, I’ve learned it also means figuring out how to function after twelve hours in a flight suit, remembering to drink water before you become mummified, and successfully paying tithe to the Porcelain Gods. And don’t get me wrong…the medicine is still the important part.

But nobody ever talks about the fact that before you can take care of the patient, you have to figure out how to take care of the idiot wearing the flight suit (that idiot is usually you). So hopefully this saves you from learning a few things the hard way. Or at the very least convinces you to pack backup underwear. Trust me on that one… I heard it from a friend.

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In the next installment of this series, we’ll move beyond flight suit survival and into the strange world of actually living this job. We’ll discuss the differences between twelve-hour “princess shifts” and the base-squatting lifestyle of 24- and 48-hour crews, including packing strategies, coping mechanisms, and the predictable stages of grieving while on the clock (joking).

We’ll also tackle base life, basemate etiquette, sleep deprivation, nutrition, long shift hygiene, and the collection of random items this experienced flight clinician carries. From emergency snacks and morale showers to emotional support go-bags and the fine line between preparedness and hoarding, we’ll cover all the things nobody teaches in orientation but everyone eventually learns the hard way.

-Clear Skies and Tail Winds